McCray Psychological Services, Inc.
Psychological Assessment
P.O. Box 7525, S. Lake Tahoe, CA 96158, Phone (530) 318-2131, Fax (866) 899-6977
Client Photo
Client Name: Smith, John
DOB: 3-28-2007
Date of Assessment: 3-29-2013
Date Client History Completed: 3-28-2013
Age When Client History Completed: 6 years 0 months 0 days
Examiner: James McCray, Psy.D.
Reason for Referral
Mrs. Smith requested a psychological evaluation to clarify whether her son has any type of
Pervasive Developmental Disorder (PDD) or any other type of learning/psychological disorder.
Two of her other children have been identified as having a PDD, and this evaluation was
recommended by John’s pediatrician and schoolteacher.
Brief Summary of Findings (Please read full report for details.)
Intellectual findings: Average nonverbal IQ
Psychological diagnosis: Autistic
Other issues: Sensory issues
Some of the psychological disorders seriously considered and ruled out: Social delays
explained by language delays alone
Recommendations: Share report with IEP team, consider autism intervention services, continues
speech and occupational therapy as appropriate and reassess current diagnosis as warranted
Procedures
Review of Prior Records
Collection and Review of Relevant History
Behavioral Observation/Mental Status Exam
Clinical Interview with John and Mrs. Smith
School observation of John
Wechsler Preschool and Primary Scale of Intelligence-Third Edition (WPPSI-III)
Adaptive Behavior Assessment System-Second Edition (ABAS-II)
Childhood Autism Rating Scale-2 (CARS-2)
Autism Diagnostic Observation Schedule-2 (ADOS-2)
Review of DSM-IV-TR Criteria for Autism and A-2sperger’s
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Background Information:
History form completed by
Mrs. Sarah Smith, mother of John.
Persons attending the current Mrs. Sarah Smith.
assessment
Parents and living situation
John and both parents live together full time.
Biological father: Mr. Jim Smith, 33 years old.
Biological mother: Mrs. Sarah Smith, 31 years old.
Languages spoken within the English.
home
Moves within John's lifetime John's family has moved twice in his life, with the most recent
move occurring when he was 4 years old, which he adjusted to
with great difficulty.
Birth:
Maternal age at birth
Prenatal care
Birth weight and length
APGAR scores
25 years old.
John's mother began receiving prenatal care within the second
trimester.
Mrs. Smith reported "I might have had a beer and sushi before I
realized I was pregnant, but neither in excess."
None reported by Mrs. Smith.
Not completed.
40 weeks (full term).
Mrs. Smith reported that John was born by emergency cesarean
section and complications included: "the labor failed to progress
and fetal distress was detected and they decided to do a Csection."
7 lb 5 oz and 19 inches long.
Unknown by Mrs. Smith.
Significant postnatal issues
None reported by Mrs. Smith.
Exposure to illicit or toxic
substances while pregnant
Difficulties with pregnancy
Amniocentesis completed
Gestation
Delivery
Medical:
Overall health
John’s overall health is good although he has mild allergies,
asthma, and a mild astigmatism.
Significant illnesses
Mrs. Smith reported, "John has had three episodes of significant
vomiting. We didn't know what caused it and took him to the
emergency room each time. Doctors gave him fluids through an
IV and he recovered quickly."
Significant injuries
None reported by Mrs. Smith.
Hospitalizations
None reported by Mrs. Smith.
Surgeries
None reported by Mrs. Smith.
Signs of seizures
None reported by Mrs. Smith.
Chronic ear infections
John has never had an ear infection.
Allergies to environment, food, Mrs. Smith reported John is allergic to the following: "whole
or medications
eggs, but [he] can tolerate products with eggs in it."
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Asthma difficulties
Currently or previously
prescribed psychotropic
medications
Hearing
Mrs. Smith indicated John has “mild” asthma and he utilized an
"Albuterol inhaler, which he only uses a few times a year."
None reported by Mrs. Smith.
Mrs. Smith reported John's hearing was tested by a specialist
when he was 4 years old, which indicated normal auditory
functioning, and she does not have concerns about John's hearing
at this time.
Vision
Mrs. Smith reported John's vision was tested by a specialist when
he was 5 years old, which indicated vision difficulties, including
"he was found to have a mild astigmatism, but not to the point of
requiring corrective lenses," and she does not have concerns
about John's vision at this time.
Eating patterns
John prefers to snack throughout the day rather than eat solid
meals.
Sleeping patterns
Mrs. Smith reported John often resists or has difficulties falling
asleep, which takes approximately 30 to 45 minutes. He does
not have nightmares or night terrors regularly. John typically
sleeps nine hours per night without waking. He usually does not
take naps.
Pica (consuming nonnutritive Mrs. Smith indicated John will sometimes try to eat/swallow
substances)
inappropriate items, such as "a little bit of play dough sometimes,
but not enough to upset his stomach."
Diarrhea or constipation
None reported by Mrs. Smith.
issues
Advanced medical tests
None reported by Mrs. Smith.
completed in past
Other medical issues not
None reported by Mrs. Smith.
addressed above
Development:
Infant temperament
Sat up without support
Crawled
Walked
Current motor skills
First functional words
Began combining words
Current language skills
Age toilet trained
Periods of significant
Mrs. Smith reported John was "great and quiet."
4 months of age.
9 months of age.
13 months of age.
Mrs. Smith does not have concerns about John's motor skills at
this time.
12 months of age.
After 36 months of age.
Mrs. Smith reported John has 50 to 100 words in his expressive
vocabulary at this time. He typically communicates in two- to
three-word phrases.
At 4 to 4½ years of age.
None reported by Mrs. Smith.
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regression
Sensory Processing Issues and Activity Level: Description: Sensory Processing Disorder is a
neurological disorder causing difficulties with processing information from the five classic
senses (vision, auditory, touch, olfaction, and taste), the sense of movement (vestibular system),
and/or the positional sense (proprioception).
Auditory (sounds) issues
Mrs. Smith reported, “He is not bothered by loud noises unless
they are sudden.
Visual (light) issues
None reported by Mrs. Smith.
Olfactory (smell) issues
Mrs. Smith reported John smells items excessively/too often.
Oral/Food issues
Mrs. Smith indicated John dislikes soft food and mixed textures.
Tactile (touch) issues
Mrs. Smith reported, "he hates touching gooey textures like
Gack."
Unusual clothes texture or fit None reported by Mrs. Smith.
issues
Vestibular (movement) issues None reported by Mrs. Smith
(e.g., enjoyment of swinging,
spinning, slides)
Proprioceptive (pressure)
Mrs. Smith reported John likes wedging himself between objects
issues
and leaning or pressing heavily on other people or objects.
High/low pain tolerance
Mrs. Smith reported John has an unusually high pain tolerance
(he does not feel pain easily).
Over- or underactive
Mrs. Smith believes John has an unusually high activity level on
a regular basis.
Focus or attention span
Mrs. Smith reported John’s attention span is very short when
others are trying to get him to focus, but it is excessively strong
on objects of interest to him.
Education History:
Early intervention services
Mrs. Smith reported John did not receive special services prior to
(services before 3 years of age) 3 years of age.
Day care
According to Mrs. Smith, John started day care at 3 years of age,
attending three days a week for an average of four hours per
day. John stopped attending day care at 4 years of age.
Services/programs between 3 According to Mrs. Smith, John started preschool at 4 years of
and 5 years of age
age, attending four days a week for an average of 4 hours per day
at Eric Jones Elementary. John stopped attending preschool
when he was 5 years of age.
Kindergarten
John began attending kindergarten at Eric Jones Elementary at 5
years of age.
Current grade & school
According to Mrs. Smith, John currently attends first grade at
Eric Jones Elementary in a mainstream/regular classroom full
time.
Special education services
Mrs. Smith indicated John first qualified for special education
services at 4 years of age under the primary category of Speech
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Behavioral difficulties
Speech therapy
Occupational therapy
Physical therapy
Autism Intervention Services
Developmental therapy
Other therapy programs
Extracurricular activities
or Language Impaired (SLI).
Mrs. Smith reported, "he sometimes gets into trouble for not
listening or following directions."
Mrs. Smith reported John has attended this service since
approximately 4 years of age which occurs four times a month
for 50 minutes per session.
Mrs. Smith reported John attended this service from
approximately 4 years of age until 5 years of age, four times a
month for 50 minutes per session.
John has never been evaluated for physical therapy, according to
Mrs. Smith.
None reported by Mrs. Smith.
John has never been evaluated for developmental therapy,
according to Mrs. Smith.
None reported by Mrs. Smith.
Mrs. Smith reported John "attended karate from 4 to 5 years of
age. He has attended swimming classes every summer since 18
months of age."
Behavioral & Psychological Issues:
Visual or auditory
Mrs. Smith does not believe John has hallucinations.
hallucinations
Psychiatric hospitalizations
None reported by Mrs. Smith.
Suicidal/homicidal ideation
None reported by Mrs. Smith.
History of abuse or trauma
None reported by Mrs. Smith.
Family history of learning
Mrs. Smith reported the following issues in relation to John:
and/or psychological disorders Depression: maternal grandmother
within the last two generations Anxiety: maternal grandmother
Other disorders/issues: Mrs. Smith indicated she "was adopted
and thus little is know about her family history."
Attempts to hurt himself
No significant issues reported.
Attempts to hurt others
No significant issues reported.
Behavioral difficulties (e.g.,
John typically tantrums four times a day, during which he will
tantrums)
"throws himself on the ground, yell and kick things," which
typically occurs when "not getting what he wants."
Mental health services
Never received, according to Mrs. Smith.
Signs of depression
None reported by Mrs. Smith.
Signs of anxiety
None reported by Mrs. Smith.
PDD: This evaluation was requested by ACRC in part to determine whether John might have a
pervasive developmental disorder (PDD), such as autism or Asperger’s. To receive a diagnosis
of autism, a person must have (1) significant qualitative impairment in social interactions, (2)
significant qualitative impairment in communication, and (3) engage in restricted repetitive and
stereotyped patterns of behavior, interests, and activities. To receive a diagnosis of Asperger’s,
a person must have delays in areas (1) and (3), but not area (2), and must have at least an
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average intelligence.
Current and prior diagnosis by Mrs. Smith reported John has never previously been evaluated
other professionals
for, or diagnosed with, a psychological disorder.
What led to the current
Mrs. Smith reported, "John doesn't seem to want to play with
assessment
other children and he has significant language delays."
Family's impressions
Mrs. Smith reportedly is unclear about John's diagnosis and was
primarily concerned with finding appropriate therapies to address
his current struggles.
Prior Assessments
(The following summaries are based on reports provided by the family and/or regional center.
There may be other assessments of John that this examiner is unaware of, were not provided, or
that were not summarized for this report as the examiner felt they were not fully relevant. Also,
the examiner is providing only a summary of the following assessments, and the reader is
encouraged to review the actual reports for more details.)
Sydney Friedman, M.S., School Psychologist, completed a Multidisciplinary Team Report on 729-10, when John was 3 years-4 months old. During the assessment, he was reported to be “very
impulsive” and “sometimes needed extra time to respond to requests.” John was administered
the Differential Abilities Scales (DAS), on which he received a Nonverbal score of 95. On the
McCarthy Scales of Children’s Abilities, he received a Motor Scale of 86. On the
Social/Emotional test, John received a Social score of 52 and a Problem Behavior score of 50,
suggesting he had significant difficulties with self-control. The examiner suggested he qualify
for special education services due to his language delays.
A Speech and Language Report was completed on 3-16-12, when John was 4 years-11 months
old. On the Preschool Language Scale-3 (PLS-3), he received an Auditory Comprehension score
of 109 and an Expressive Communication score of 64. He was reported to have made
tremendous improvement in his overall language development, and the examiner concluded John
is an “entertaining young man who qualifies for speech or language services at this time.”
Behavioral Observations During Evaluation
At the beginning of the evaluation, the examiner let Mrs. Smith know he would be asking
questions about John’s history and behaviors as well as openly discussing the examiner’s clinical
impressions. She was asked to let the examiner know, in advance or during the interview, if he
asked a question or was discussing a topic she did not want John to overhear. At no point did
she indicate she was uncomfortable with the discussion or that she did not want to discuss an
issue in front of John.
Social interactions: John was a very handsome boy who appeared her age. No dysmorphic
features were noticeable, although a large mole was evident above his left eyebrow. He had
good hygiene and grooming. He appeared very focused on toy cats for the first half hour of the
3-½ hour evaluation. During this time, he focused exclusively on the toy cats and engaged in
lots of physical play. The examiner attempted to engage John in a conversation about his actual
pets, but without success. In fact, the examiner tried on multiple occasions to engage him in a
conversation about several different topics, but John would only answer direct questions and
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only ask functional questions of the examiner. He often enjoyed creating movie scenarios, such
as referring to a certain section of the office as “Pride Rock” (from the movie Lion King), and
called each of the cats a different character. While this behavior seemed relatively typical for a
six-year-old boy, the extent to which he perseverated on this topic and dictated how others
should act or respond was unusual. At other times, when asked whether what he was describing
was a real event or a movie scene, he often insisted it was real when it clearly was not. This
reportedly is a frequent issue for John. No self-stimulatory behaviors were observed during the
evaluation. The examiner attempted to engage him in direct play, but there was a significant lack
of reciprocity in his social interactions.
Verbal interactions: John could express his thoughts and wants in simple sentences with mild
articulation difficulties. However, he struggled with spontaneously responding to questions, and
it seemed to take him a while to process some questions asked by others and formulate a
response. The examiner heard him repeat a few of the examiner’s questions or phrases in a rote
manner, but more often, he was quoting lines from movies. John tended to speak in a somewhat
demanding tone; such as when wanting something, he would say, “Turn this on,” in a strong
voice, without spontaneously saying “please” or “thank you.” However, when prompted by Mrs.
Smith, he would then use better manners. Mrs. Smith was very consistent in encouraging him to
use better manners, and John’s style of communicating appeared due to a lack of awareness of
other people’s responses or emotions rather than how a child might behave who is used to getting
their way. He demonstrated little desire or ability to engage in a conversation.
Testing interactions: It was extremely difficult to engage John in intellectual testing. This
appeared due in part to functional language delays, but even more so because of his lack of
desire to perform for or please others. He often became sidetracked in his own thoughts or
interests. For part of the testing, he appeared very socially aloof and had an extremely flat affect.
Attempts at humor and tickling resulted in little response from John. Later on, he became much
more animated, which made testing more difficult as he became more focused on his specific
toys rather than completing the testing. During the Matrix Reasoning subtest, he created a very
ritualistic routine of making an exaggerated face showing that he was thinking very hard, then a
very surprised, excited look before pointing to the correct answer. He did exactly the same set of
reactions a dozen times and did not direct these expressions towards the examiner, and the
examiner’s response to what he was doing made little difference. At another time, he only
wanted to give silly answers, which, again, is somewhat age-appropriate; yet, his inability to
become refocused despite frequent attempts from the examiner was unusual. For example, when
asked what has wheels, he would laugh and say “a banana,” and then looked around the room
and found another item when the question was repeated. During the ADOS-2, a play based
assessment for autism, he appeared uncomfortable engaging in imaginary play independently or
with the examiner. He could only demonstrate a routine task when asked for each specific step.
John could identify items within a picture but greatly struggled with telling a story based on
pictures within a book. John did not seem to want to engage the examiner in a conversation, or
talk about his emotions and relationships with others. This appeared largely due to John’s lack
of awareness of typical social interactions rather than a reluctance to address personal issues with
Dr. McCray. John could not identify any friends, why people would want to marry one another
and said he did not feel lonely.
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Behavioral Observations at School
With the family’s permission, the examiner observed John at school for approximately one hour.
The examiner discussed the best time for this to be conducted and chose a time period that
included classroom time when the teacher was giving a lesson, a group activity time within the
classroom, and part of his recess.
While many of the other children in the classroom appeared interested in the examiner and were
mildly distracted by his presence, John showed little interest in the examiner. Instead, he
appeared content with making drawings on his paper while the teacher was talking. He followed
her directions well but did need a few extra reminders to focus. John’s social struggles became
much more evident during the group activity time. The teacher told the children to find a partner
for the next activity. While most children were excited about this and quickly tried to find their
friends, John seemed to wander aimlessly about the classroom. He did not appear nervous or shy
about approaching others as much as he did not have a strong interest in interacting with peers.
The teacher eventually realized John did not have a partner and helped him find another child to
work with. John had difficulty engaging in cooperative tasks with his partner, which was clearly
frustrating to the other child. John often chose to complete parts of a task without first
consulting the other child and was never seen sharing pride in his accomplishments with his
partner or the teacher.
John excitedly ran out of the classroom when the recess bell rang. He quickly found a basketball
and enjoyed throwing it at a hoop, but did not try to engage others in basketball. In fact, when
another child approached John to try to join him, John turned his back to him and walked away.
John was fairly active during recess and often ran about, like many of the other children, but,
unlike his peers, he did not try to engage others. The examiner talked to one of the recess
monitors, who said this was fairly typical behavior for John. Mrs. Smith later said she had heard
the same from teachers and that he often chose to play by himself when she took him to social
areas like Chuck-E-Cheese.
Test Results
It is important to realize that test scores may be interpreted in a number of different ways and
that the validity (accuracy) of the results is often dependent upon the person’s age and the effort
he placed into testing. For example, the validity of IQ tests on a 2-year-old is limited, whereas
on a 9-year-old it is much more accurate. Various measures interpret their scores in different
manners, which can be confusing to the reader. For example, the Wechsler classification system
(one of the most popular systems) considers mental retardation to be an IQ below 70, a
borderline IQ to be between 70 and 79, a low-average IQ to be between 80 and 89, and an
average IQ to be between 90 and 109. However, the DSM-IV-TR, which is used when providing
a clinical (official) diagnosis, considers mental retardation to be an IQ below 71 and a
borderline IQ to be between 71 and 84. Thus, there is often debate as to whether an IQ between
80 and 84 is considered to be in the low-average or borderline range. Dr. McCray generally
follows the DSM-IV-TR definition, as this is what all other diagnoses are based on. However,
interpretation will depend upon the apparent validity of scores and professional clinical
judgment.
Page 9 of 16
General intellectual testing description: John was administered the Wechsler Preschool and
Primary Scale of Intelligence-Third Edition (WPPSI-III), which is a series of tests to evaluate
intellectual abilities. It consists of two scales: the verbal scale and the performance scale. Each
of these scales has several subtests. With the verbal scale, the examiner gives questions orally
and the examinee gives a spoken response. The performance scale includes tasks such as puzzles
and design imitation with blocks. While this test is a good predictor of future learning and
academic success, it cannot determine motivation, curiosity, creative talent, work habits, study
skills, or achievement in academic subjects.
IQ testing results: John received a Full Scale IQ score of 82, which represents a low-average IQ.
However, this total score does not fully or accurately reflect his relative strengths and
weaknesses, and thus is not a particularly good way to summarize his overall intelligence. John
received a Performance IQ of 90, which represents an average nonverbal intelligence. The
examiner suspects his scores may have been a little higher if he had tried harder on certain
subtests and had not been so easily distracted. His Verbal IQ was generally in the borderline
range, which represents a relative weakness in his language development, especially his
expressive language. Subtest scores within each composite were relatively similar. Scores and
their descriptions are as follows:
Wechsler Preschool and Primary Scale of Intelligence-Third Edition (WPPSI-III)
Attribute Measured
Score Composites
75
Verbal
Language expression, comprehension, and listening
90
Performance
Nonverbal problem-solving, perceptual organization, and
visual-motor proficiency
-Processing Speed Visual-motor quickness, concentration, and persistence
82
Full Scale
Combined composite scores
Verbal Subtests
Score Subtest
Attribute Measured
5
Information
Factual knowledge, long-term memory and recall
6
Vocabulary
Abstract reasoning, verbal categories, and concepts
5
Word Reasoning Verbal reasoning, word knowledge, and logic skills
Performance Subtests
Score Subtest
Attribute Measured
8
Block Design
Spatial analysis and abstract visual problem-solving
10
Matrix Reasoning Visual information processing and abstract reasoning skills
8
Object Assembly Visual analysis and construction of objects
Adaptive skills measure: Mrs. Smith was asked to complete the ABAS-II questionnaire, which
addressed John’s adaptive behaviors and independent living skills. The examiner reviewed Mrs.
Smith’s responses and found them to be consistent with prior reports and the his experience of
John during the evaluation. The focus of this instrument is on the functions an individual
actually performs without the assistance of others. John’s General Adaptive Composite (GAC)
score was 62, which represents very delayed skills and is most likely due to him having autism.
Scores are as follows:
Adaptive Behavior Assessment System-Second Edition (ABAS-II)
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Composite Scores
GAC
Conceptual
Social
Practical
Conceptual Subtests
Communication
Functional Pre-Academics
Self-Direction
Social Subtests
Leisure
Social
Practical Subtest
Community Use
Home Living
Health & Safety
Self-Care
Motor
Standard Score
62
65
50
58
Standard Score
3
8
4
Standard Score
2
1
Standard Score
2
3
6
3
9
Adaptive Level
Very Low
Very Low
Very Low
Very Low
Adaptive Level
Very Low
Average
Very Low
Adaptive Level
Very Low
Very Low
Adaptive Level
Very Low
Very Low
Borderline
Very Low
Average
Autism screening measure: The examiner completed the Childhood Autism Rating Scale-2
(CARS-2), which is a 15-item behavioral rating scale. It is designed as a screening tool to
identify children with autism and help identify possible signs of autism (or autism spectrum
disorder). The CARS-2 ratings are comprised of behavioral observations, parental reports, and a
review of relevant records. Scores are as follows:
Childhood Autism Rating Scale-2 (CARS-2)
Raw Score T-Score
Interpretation
32
42
Mild-to-moderate symptoms of autism spectrum disorder
Standardized Autism measure: John was administered the Autism Diagnostic Observation
Scale-2 (ADOS-2), which is a standardized, semi-structured, observation assessment tool that
allows the examiner to observe and gather information regarding an individual’s social behavior
and communication in a variety of different social communicative situations. Module 3 was
utilized based on John’s age and language abilities. John’s total score exceeded the autism cutoff
point, suggesting a diagnosis of autistic disorder. His Level of Autism score was 9, suggesting
he has a high level of autism compared to other children with this disorder. Results are as
follows:
Social Affect: John was unable to provide an account of a routine or non-routine event
unless asked specific questions. He would answer direct questions asked by the examiner
but there was little sense of reciprocal conversation. John had some spontaneous and
descriptive gestures, but less than would be expected for his age. He used poorly
modulated eye contact to initiate, terminate, or regulate social interactions. John directed
some facial expressions towards others, but less than would be expected for his age. He
showed little pleasure during interactions unless focusing on a topic of interest to him.
The overall quality f his social interactions and responses were mildly unusual. Most of
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John’s communication was in response to direct questions and his overall interactions
were one-sided and mildly awkward.
Restricted and Repetitive Behaviors: John’s use of words tended to be overlay repetitive.
He demonstrated some signs of sensory issues, such as not wanting to touch certain soft
toys within the examiner’s office. He was briefly observed flapping his hands when
excited and walking on his tip-toes. John focused on cats regularly to the point of them
interfering with his ability to socially engage others.
Autism Diagnostic Observation Scale-2 (ADOS-2)-Module 3
John’s Autism
Score Cutoff
Social Affect (SA)
Restricted and Repetitive Behavior
(RRB)
Overall Total (SA + RRB)
Level of Autism Spectrum
Autism
Spectrum
Cutoff
5
10
15
9
7
9 (High)
Listed below are the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text
Revision (DSM-IV-TR) criteria for autism and Asperger’s. To be diagnosed with autism, a
person must clearly meet at least six criteria, with a minimum of two criteria from section 1 and
at least one criterion from sections 2 and 3. To be diagnosed with Asperger’s, a person must
meet at least two criteria from section 1 and one criterion from section 3, but have no clinically
significant delay in cognitive development or language. The examiner defines meeting criteria
as falling in the “significant” range. Results follow:
1. Qualitative impairment in social interaction, as manifested by at least two of the following:
SignNot
(a) marked impairment in the use of multiple nonverbal behaviors such
ificant Mild Sign- as eye-to-eye gaze, facial expression, body postures, and gestures to
ificant regulate social interaction. John only occasionally seeks social eye
contact with others, and when he does, it is typically very brief. He has
X
an expressive face, but often seems to be acting out emotions and does
not his expressions towards others on a regular basis.
X
(b) failure to develop peer relationships appropriate to developmental
level. John often plays by himself on the playground. When playing
with others, he wants people to do things his way and has difficulty with
cooperative play. He has never developed a special friendship with
another child and appears content with his limited friendships. When at
home, he also appears content to play on his own and typically only
seeks out adults when he needs help with something rather than just for
social engagement.
X
(c) lack of spontaneous seeking to share enjoyment, interests, or
achievements with other people. John will only sometimes share his
interests and achievements with others, but not on a frequent basis and
much less often than would be expected for his age. More often, he is
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pointing out an object of interest because he wants an adult to buy it for
him, which is not a social sharing of his interest.
X
(d) lack of social or emotional reciprocity. John will sometimes
spontaneously hug or kiss his parents, but most of the time they have to
encourage this to occur. He does not consistently show a positive
reaction to praise from others. John will be curious and ask many
questions when seeing someone is upset, but the extent of his empathy is
questionable.
2. Qualitative impairments in communication as manifested by at least one of the following:
SignNot
(a) delay in, or total lack of, the development of spoken language (not
ificant Mild Sign- accompanied by an attempt to compensate through alternative modes of
ificant communication such as gesture or mime). John’s receptive language
skills are adequate, but his expressive language skills are a significant
X
relative weakness. While he can express his wants and needs verbally,
he uses few nonverbal gestures to compensate for his language delays.
The family said he did not point to objects with an index finger until
approximately 4 years old, and even now does this only infrequently.
X
(b) in individuals with adequate speech, marked impairment in the
ability to initiate or sustain a conversation with others. John is unable
to carry on a social conversation at a level appropriate for his language
development. He will sometimes go into monologues about his interests
rather than engage in truly reciprocal conversations. Questions he asks
of others are typically fact based, rather than used to socially engage
others.
X
(c) stereotyped and repetitive use of language or idiosyncratic
language. John used to engage in lots of immediate echolalia (repeating
of words), but does so to a lesser extent now. Currently, he often quotes
lines from movies, which are only sometimes relevant to the situation.
(This is known as idiosyncratic language.)
X
(d) lack of varied, spontaneous, make-believe play or social imitative
play appropriate to developmental level. Most of John’s make-believe
play involves re-creating scenes from movies, but he has little unique
creative play. He has very little social imitative play. More often, he
will copy another person because he is interested in their activity rather
than attempting to socially engage the other person.
3. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as
manifested by at least one of the following:
SignNot
(a) encompassing preoccupation with one or more stereotyped and
ificant Mild Sign- restricted patterns of interest that is abnormal either in intensity or
ificant focus. John becomes intensely focused on certain topics. For example,
after watching a movie, he will sometimes perseverate on a certain
X
character by constantly pretending to be that character and will try to get
others to be the other characters. When the examiner observed John, he
was obsessed with pretending to be like an animal from a popular
television show.
X
(b) apparently inflexible adherence to specific, nonfunctional routines
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X
X
or rituals. John is hesitant of new situations, such as going to
Disneyland, whereas most children would have been excited. He has
difficulty with changes, but no specific nonfunctional routines.
(c) stereotyped and repetitive mannerisms. John flaps his hands when
excited. He likes to walk on his tiptoes, which he does throughout the
day. If not re-creating movie scenes with his toys, he will line them up
in a very specific manner and becomes upset if another person disturbs
the line. He will sometimes stare at the wheels of a toy car.
(d) persistent preoccupation with parts of objects. John typically
focuses on an entire toy or object rather than just a small part of one,
except for wheels of a toy car, which was addressed in the criterion
above.
Impressions
Summary of client history: John is a six-year-old boy living with his parents. He was born full
term by emergency cesarean section after fetal distress was detected. However, there were no
significant post-natal issues and he did not require specialized medical care after his birth.
John’s overall health is good, with the exception of mild allergies and asthma. He has passed a
hearing test at 4 years of age and vision testing indicates he has a mild astigmatism that does not
yet require corrective lenses. John completed his physical developmental milestones in a
relatively normal time frame and currently has adequate motor skills. He said his first words in a
normal time frame, but his overall language skills were slow to develop, and he currently has a
relative weakness in his expressive language skills. John demonstrates some mild-to-moderate
signs of a sensory processing disorder as he is overly upset by sudden noises, often smells
objects, dislikes certain food textures, and dislikes touching “gooey” textures. He also likes
especially deep or strong proprioceptive input, which may explain part of his higher activity
level. John has qualified for speech therapy services since approximately four years of age under
the category of a speech of language impairment and has received individualized speech therapy
since that time. He typically is not self-injurious, nor is he aggressive towards others, but he
does throw multiple tantrums a day. John has never previously undergone an evaluation for a
Pervasive Developmental Disorder (PDD), such as autism.
Summary of intellectual and adaptive testing (Axis II issues): John was administered the
WPPSI-III for the current assessment to help determine his overall cognitive level of functioning.
He demonstrated an average nonverbal IQ, as seen by his performance IQ score of 90. (Scores
of 85 to 115 are generally considered to fall within the average range.) John’s verbal score of 75
indicates a relative weakness in his language skills as this score falls within the borderline range.
It is important to realize this test focuses primarily on a child’s expressive language skills, which
prior tests indicate are more of a weakness for John than his receptive language skills. He did
not have the attention span to complete any of the processing speed subtests, and thus they were
not administered. Given the disparity between John’s verbal and nonverbal IQ scores, his fullscale IQ is not a good means to summarize his overall intelligence. While a significant
difference in a person’s verbal and nonverbal IQ will sometimes lead to a diagnosis of a learning
disability or language disorder, Dr. McCray believes these score variations may better be
explained by a PDD, such as autism. John’s adaptive skills, as reported by Mrs. Smith on the
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ABAS-II, were significantly delayed in most areas, which this examiner also suspects is due to
John having autism.
Summary of PDD issues or other psychological issues (Axis I issues): John demonstrates many
clear signs of having autism, which is a type of Pervasive Developmental Disorder (PDD).
Specially, a person with autism has difficulties in three major areas: their social skills, language
skills, and stereotyped/repetitive behaviors or interests. In John’s case, his social difficulties are
evidenced by his minimal social eye contact and inappropriate sharing of facial expressions,
limited interest in peer interactions, and lack of sharing his interests or achievements with others.
These difficulties do not appear due to just his language delays or shy personality, because even
when comfortable or engaging in nonverbal play, he chooses to be on his own rather than engage
others. John’s language development is also more typical of a child with autism compared to a
child who has strictly language delays, as he uses few gestures to compensate for his delays.
Additionally, John does not engage in conversations appropriate to his language level, he
engages in some repeating of others for no apparent reason (echolalia), and he has limited makebelieve or social imitative play. John’s tendency to become overly focused on certain topics and
engages in self-stimulatory behaviors (such as hand-flapping and lining up of toys) is also very
typical of a child with autism. More specifically, when reviewing these behaviors in light of the
DSM-IV-TR, John meets 8 out of 12 criteria for autism, when only 6 are required for a diagnosis
of autism. Quantitative measures appear to support this diagnosis, as seen by John’s scores on
the ADOS-2 and CARS-2. It is important to realize that approximately 70% of children with
autism cognitively function in the mental retardation range. However, John appears to have at
least an average nonverbal intelligence, which, in combination with his relative strengths on the
autism spectrum, causes this examiner to consider him as “high functioning.” (The term “high
functioning” is not an official DSM term; therefore, its definition will vary among professionals.)
Parent Discussion: The examiner discussed the testing results and his clinical impressions with
Mrs. Smith. While she was not particularly surprised by the diagnosis, it was clearly hard to
hear. The Smiths appear to have provided a very loving environment for John and have done
their best to provide appropriate therapies for him from a young age. It is typical for a parent to
question whether they could have done anything to cause the disorder, and the examiner believes
it is very important Mr. and Mrs. Smith realize there is nothing they have done to cause this
disorder. In fact, during the evaluation, Mrs. Smith showed excellent parenting skills and great
patience, which have undoubtedly helped John progress as well as he has.
Diagnosis
Axis I: 299.00
Autistic Disorder (high functioning)
Axis II: V71.09
No Diagnosis (average nonverbal IQ)
Axis III: Mild Astigmatism
Hypoglycemia
Sensory Processing Disorder
Recommendations
1. Autism intervention: Given John’s diagnosis, he would benefit from an evaluation for
enrollment in a program for children with a pervasive developmental disorder. Such
programs typically emphasize social skills training, speech therapy, and structured behavioral
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2.
3.
4.
5.
6.
7.
8.
interventions. The exact type and nature of this therapy are best determined by the experts
who provide this service. Also, while studies may suggest an “ideal” or “optimal” level, the
examiner encourages therapists and family members to base their decisions about the extent
of any particular therapy on how John responds to that therapy. Given his average-or-higher
intelligence, it is important his placement is carefully considered to ensure it is the least
restrictive environment.
IEP: Given John’s current diagnosis, the family may want to request a new IEP to determine
whether he may better qualify under a different special education category, such as “AutisticLike.”
Occupational therapy: Continued occupational therapy is encouraged given reports of his
sensory issues.
Speech therapy: Continued speech therapy is also encouraged given his relative weakness in
his expressive language skills.
Awareness of his/her disorder: John appears quite content with his current social
interactions and has limited awareness of how he differs from his peers. It is not uncommon
for children with an average IQ and autism to eventually realize they are different from
others, which leads to significant frustration and sometimes depression. Therefore, the
examiner encourages the family to be open with John about his differences and help him find
skills or hobbies that he is proud of and can help maintain his self-confidence.
Reevaluation: John’s progress should be carefully monitored by his parents and care
providers (i.e., teachers, pediatrician, etc.) to determine whether further testing is warranted
in the future. For example, should John show marked improvement in skills or a lack of
appropriate development/progress, then a reevaluation of his diagnosis may be warranted. In
addition, intellectual testing results tend to become more accurate as a child ages, as does a
child’s diagnostic presentation.
Other resources: The Smiths may benefit from becoming involved with organizations that
focus on children with special needs, such as WarmLine (www.warmlinefrc.org or 916-9229276). Such organizations can provide parents with support groups, behavior management
techniques, education about autism, and other valuable resources that may support a family
with a child who has autism.
Record tracking: The Smiths are encouraged to create a system for tracking the numerous
reports and paperwork that will most likely accumulate throughout John’s life. Bringing
these reports to their various meetings will help ensure goals are more reliably tracked and
information is provided in the most expedient manner. The examiner has found the best
system includes purchasing a 2-inch-thick three-ring binder with at least five divider tabs.
Each tab should represent different types of meetings/evaluations such as IEPs, psychological
evaluations, speech/language evaluations, occupational therapy evaluations, etc. The Smiths
should obtain a copy of each assessment and place it chronologically within its appropriate
section. It is important they keep a permanent copy for their records. The examiner also
encourages them to put in writing any requests to the agencies from which they are
seeking/receiving services.
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James McCray, Psy.D.
Licensed Psychologist
PSY 17068